Can cangrelor be used as bridge therapy for a patient with a past percutaneous coronary intervention (PCI) undergoing non-cardiac surgery?

Cangrelor as Bridge Therapy for Non-Cardiac Surgery After PCI

Cangrelor may be considered as bridge therapy for patients with prior PCI requiring non-cardiac surgery within 1-12 months of stent placement when both oral antiplatelet agents must be discontinued perioperatively, though this remains inadequately studied and is currently being evaluated in ongoing trials. 1

Current Guideline Recommendations

The 2024 AHA/ACC/ACS perioperative guidelines explicitly acknowledge that intravenous antiplatelet therapy as a bridge for nondeferrable surgery in patients 1-6 months post-PCI who continue to need DAPT has been inadequately studied. 1

Key Timing Considerations:

• Elective non-cardiac surgery should NEVER be performed within 30 days of PCI due to catastrophic risks of MI, stent thrombosis, bleeding, and mortality 1
• Surgery is highest risk within the first 3 months post-PCI, with MACE rates of 10.5% when performed <30 days versus 2.8% when >3 months 1
• If surgery cannot be deferred beyond 1 month and both antiplatelet agents must be stopped, a bridging strategy with cangrelor, tirofiban, or eptifibatide may be considered 1

Evidence for Cangrelor Bridging

Established Data:

• The BRIDGE trial demonstrated that cangrelor maintained platelet inhibition in patients awaiting CABG surgery and enabled rapid return to baseline platelet function upon cessation, with greater platelet inhibition without excessive major bleeding 1
• Cangrelor's pharmacologic properties make it theoretically ideal for bridging: rapid onset, potent platelet inhibition, and restoration of platelet function within 1 hour of discontinuation 1, 2

Critical Gap in Evidence:

• The MONET trial is currently underway to evaluate cangrelor as bridging strategy specifically for non-cardiac surgery in patients within 12 months of PCI 1
• No established randomized data exist for cangrelor bridging in non-cardiac surgery, only cardiac surgery (CABG) 1
• Real-world case series show feasibility but lack robust safety/efficacy data 3, 4

Practical Algorithm for Decision-Making

Step 1: Assess Timing from PCI

• <30 days post-PCI: Defer all elective surgery; only proceed if truly life-threatening indication (e.g., cancer resection) 1
• 1-3 months post-PCI: High-risk period; strongly consider deferring surgery if possible 1
• 3-6 months post-PCI: Moderate risk; bridging may be reasonable if surgery cannot be deferred 1
• >6 months post-PCI: Lower risk; consider whether bridging is necessary based on individual thrombotic risk 1

Step 2: Determine if Aspirin Can Be Continued

• If aspirin can be maintained perioperatively, surgery may proceed after 1 month with P2Y12 inhibitor discontinuation alone 1
• This is the preferred strategy when feasible 1

Step 3: If Both Agents Must Be Stopped

• Cangrelor bridging may be considered, especially within 1 month of stent implantation 1
• Recognize this is off-guideline use with limited evidence 1
• Requires multidisciplinary team coordination (cardiology, surgery, anesthesia, pharmacy) 1, 3, 4

Cangrelor Bridging Protocol (Based on Real-World Experience)

When bridging is deemed necessary:

Preoperative Phase:

• Discontinue oral P2Y12 inhibitor 3 days before surgery 4
• Start cangrelor infusion at bridging dose (0.75 µg/kg/min) when oral agent discontinued 4
• Stop cangrelor 6-7 hours before surgical incision to allow platelet function recovery 4

Postoperative Phase:

• Resume cangrelor 9 hours after surgery (range 3-15 hours depending on hemostasis) 4
• Continue until oral P2Y12 inhibitor can be safely restarted 4
• Transition appropriately to avoid gap in platelet inhibition 5

Critical Caveats and Pitfalls

Major Limitations:

• No FDA approval for bridging indication in non-cardiac surgery 6
• The FDA denied approval for bridging in 2014 due to lack of evidence 6
• Current use is off-label and based on extrapolation from CABG data 1

Bleeding Considerations:

• While major bleeding was similar to clopidogrel in PCI trials, minor bleeding was increased with cangrelor 1, 2
• Real-world bridging series showed mean hemoglobin drops <2 g/dL but required blood transfusions in 38% of patients 4

Thrombotic Risk:

• One cardiac death occurred 3 hours after cangrelor discontinuation prior to surgery in a real-world series 4
• This underscores the critical importance of timing discontinuation appropriately before surgery 4

Alternative Consideration:

• Glycoprotein IIb/IIIa inhibitors have no established data as bridging strategy and should not be used 1

Bottom Line for Clinical Practice

In real-world practice, cangrelor bridging for non-cardiac surgery post-PCI should be reserved for truly nondeferrable surgery in patients at highest thrombotic risk (within 1-6 months of PCI, especially with complex stenting or prior stent thrombosis) when both antiplatelet agents must be discontinued. 1 This requires explicit informed consent about off-label use, meticulous multidisciplinary planning, and recognition that definitive evidence supporting this strategy is lacking and awaits completion of the MONET trial. 1